People With HIV at Higher Risk of COVID-19 Infection Even After Vaccination, Study Finds

Researchers found that fully vaccinated people with HIV have a 41% higher risk of COVID-19 breakthrough infection compared with people without HIV.

COVID-19 vaccination has been proven effective, but findings from a study by Johns Hopkins University investigators published online as a preprint showed that people living with HIV have an increased risk of breakthrough infections compared with people without HIV.

For people with advanced or untreated HIV, the CDC currently recommends a booster vaccine either 28 days after the second mRNA dose or 2 months after the single Johnson & Johnson (J&J) dose. However, the authors of the study—which has not yet been peer reviewed—argued that recommendations for additional vaccine doses should be expanded to all people living with HIV.

The authors analyzed data from 4 longitudinal cohorts from integrated health systems and academic health centers in the US. They sorted data by vaccination type and by immune or viral suppression status at the time of vaccination. Participants were followed to the date of breakthrough infection, death, disenrollment from the health system, 210 days (7 months) after the date they were fully vaccinated, or until September 30, 2021, whichever occurred first.

After making necessary exclusions due to vaccine mixing within the primary series, a total of 109,599 people were included in the study, with 31,840 participants living with HIV and 77,759 living without HIV. The population was dominantly male (92%) and aged 55 and older (71%). Most (41%) participants were non-Hispanic Black. A small number of participants received the J&J vaccine (6%); most received Pfizer (51%) or Moderna (43%).

“Although we did not match on vaccine type, the distribution of vaccine type by HIV status did not differ by more than 2 percentage points,” the authors noted, adding that 26% of participants with HIV received a booster dose after the primary series compared with only 12% of those without HIV.

The overall incidence rate of breakthrough infections was 35 per 1000 person-years, with a 2.3% incidence of breakthrough infection in the entire population 7 months after being fully vaccinated. Although they still had a relatively low rate of breakthrough infection, people with HIV had a higher incidence (2.8%) compared with people without HIV (2.1%). Incidence rate varied by vaccine type—J&J (3.3%), Pfizer (2.6%), and Moderna (1.7%)—and risk of breakthrough infection was consistently higher for people with HIV.

According to the authors, these findings are consistent with studies showing lower efficacy of the J&J vaccine compared with mRNA vaccines and, further, more breakthrough infections among people with the Pfizer primary series compared with Moderna.

After controlling for HIV status, researchers found a 41% higher risk of COVID-19 breakthrough infection in fully vaccinated people with HIV compared with other groups. Additionally, they found no statistically significant differences in risk when comparing viral loads and CD4 counts among participants with HIV, suggesting all fully vaccinated people with HIV are more susceptible to breakthrough infection.

Among participants with HIV, older age (aged 55-74 years) was linked to decreased risk of breakthrough, while younger age (aged 18-24 years) was linked to increased risk, compared with individuals aged 44 to 54 years. According to the authors, this association may be representative of behavioral changes made to follow COVID-19 guidelines rather than biological factors.

The authors also noted that an association between history of COVID-19 before vaccination and increased risk of breakthrough infection among people with HIV may be connected to the level of exposure or adoption of prevention measures.

“For example, [people with HIV] with increased exposure (perhaps occupational) prior to being fully vaccinated may have had persistent increased exposure post-full vaccination, leading to increased breakthroughs,” they said. “This may also reflect the increased burden of underlying comorbidities among people aging with HIV that increased their vulnerability to COVID-19.”

The authors noted these findings are not necessarily reflective of the total US population living with HIV, as they only included people with health care access in the study.


Coburn SB, Humes E, Lang R, et al. COVID-19 infections post-vaccination by HIV status in the United States. medRxiv. Preprint published online December 6, 2021. doi:10.1101/2021.12.02.21267182